ProCare HospiceCare
Spring/Summer Edition 2013
On-Demand Clinical News
Clinical Corner:
A Comparison of Selected Cough
Syrups by Drug Class and Cost
Cody Midlam, PharmD, CGP
There are many commercially available formulations of cough
syrups available, and many contain different ingredients found in
similar drug classes. A brief listing of some of the most common
cough syrup preparations are listed below along with the drug
classes of their ingredients and average retail prices.
Hydromet® contains Hydrocodone (opioid) 5mg and Homatropine
1.5mg (anticholinergic). The brand name Hycodan® is no longer
manufactured, but can be found as Hydromet®. Average retail price
is $87.44 for 473mL bottle or ~$0.92/ 5mL dose.
Cheratussin AC contains Guaifenesin 100mg (expectorant) and
Codeine 10mg (opioid)/ 5mL. Robitussin AC is no longer available
as a trade name, but can be found as Cheratussin AC. Average retail
price $7.05 for a 120mL bottle or ~$0.29/ 5mL dose.
Promethazine cough syrup contains Codeine 10mg (opioid) and
Promethazine (Phenergan) 6.25mg (antihistamine)/ 5mL. Average
retail price is $32.75 for 473mL ~$0.35/ 5mL dose
Tussionex® contains Hydrocodone 10mg (opioid),
Chlorpheneramine 4mg (antihistamine)/ 5mL. Average retail price
is $307.84 for a 473mL bottle or ~$3.24/ 5mL dose. **Please note:
This medication is a non-preferred cough syrup and typically
requires your hospice clinical manager’s approval due to higher
cost**
The average retail prices listed above have been found online at
www.drugstore.com; accessed March 17, 2013. Average wholesale
price and specific hospice contracts may result in higher or lower
cost estimates.
References:
Lexi-Comp OnlineTM. Lexi-Drugs OnlineTM , Hudson, Ohio: LexiComp, Inc.; March 17, 2013
Updated Drug Disposal Guidelines (2013)
Gerry McKeegan, RPh.
The new federal prescription drug disposal guidelines
recommend mixing unwanted drugs with unpalatable
substances (ie: kitty litter, used coffee grounds) and
placing in a non-descript container before discarding in
the trash, unless the prescribing information specifically
states the drug is to be flushed down the toilet or sink.
The current federal prescription drug disposal guidelines
state specifically that the following drugs should be
flushed down the toilet instead of being disposed of in
the trash (as described above): Abstral®, (sublingual
Fentanyl), Actiq® (oral transmucosal Fentanyl), Avinza®
(ER Morphine), Daytrana® (transdermal
Methylphenidate patch), Demerol® (tablets and oral
solution Meperidine), Diastat® (rectal gel Diazepam),
Dilaudid® (tablets and oral liquid Hydromorphone),
Duragesic® (ER Fentanyl patch), Embeda® (ER Morphine
/Naltrexone), Exalgo® (ER Hydromorphone), Fentora®
(buccal Fentanyl), Kadian® (ER Morphine), Methadone
(tablets and oral solution), Morphine (IR tablets and oral
solution), MS Contin® (ER Morphine), Nucynta® (ER
Tapentadol), Onsolis® (buccal Fentanyl), Opana® (IR and
ER Oxymorphone), Oxecta® (IR Oxycodone), Oxycodone
(IR capsules, and oral solution), Oxycontin® (ER
Oxycodone), Percocet® (Acetaminophen/Oxycodone),
Percodan® (Aspirin/ Oxycodone), Xyrem® (oral solution
Sodium Oxybate). The FDA has determined this is the
most appropriate route of disposal for these drugs to
ensure the least risk to safety, reducing the danger of
unintentional use or overdose and illegal abuse.
Additional reminders: Before throwing out a medicine
container, such as a pill bottle, remember to scratch out
all information on the prescription label to make it
unreadable. You may also contact your county or city
government’s household trash and recycling service to
see if there is a medication take-back program in your
area.
For additional information on drug disposal, contact the
FDA: 1-888-INFO-FDA (1-888-463-6332).
References:
Disposal of Unused Medicines: What You Should Know.
http://www.fda.gov/drugs/resourcesforyou/consumers/
buyingusingmedicinesafely/ensuringsafeuseofmedicine/s
afedisposalofmedicines/ucm186187.htm
Sulfa Allergy Cross-Sensitivity…
Can a patient with sulfa allergy take
morphine sulfate?
Cody Midlam, PharmD, CGP
Joelle Potts, PharmD, CGP
Occasionally, we are asked whether patients with a sulfa
allergy can safely take morphine sulfate, or another
medication that has “sulfate” as part of its generic name.
Patients with a sulfa allergy are typically allergic to
sulfonamides (a.k.a. sulfa drugs), and there are three
classes of sulfa drugs based on their chemical structure:
sulfonylarylamines, nonsulfonylarylamines, and
sulfonamide moiety-containing drugs. Examples of each
of these categories are as follows:

Sulfonylarylamines: Includes sulfa antibiotics such as
sulfamethoxazole (in Bactrim) and protease
inhibitors such as darunavir (Prezista®).

Nonsulfonylarylamines: Includes carbonic anhydrase
inhibitors such as acetazolamide (Diamox®); COX-2
inhibitors such as celecoxib (Celebrex®); loop
diuretics such as furosemide (Lasix®) and torsemide
(Demadex®); sulfonylureas such as glipizide
(Glucotrol®) and glyburide (DiaBeta® and others);
thiazides and related compounds such as
hydrochlorothiazide and metolazone (Zaroxolyn®);
and miscellaneous other agents including tamsulosin
(Flomax®).

First and Second Generation
Antipsychotics— a Focus on
Zyprexa® (Olanzapine)
Sulfonamide moiety-containing drugs: Includes 5-HT
agonists such as sumatriptan (Imitrex®); and
miscellaneous other agents including topiramate
(Topamax®).
Oftentimes, patients with an allergy to sulfa antibiotics (in the
sulfonylarylamine category) do not need to avoid medications
in the nonsulfonylarylamine or sulfonamide moietycontaining drug categories, as evidence suggests that allergic
cross-sensitivity between the different classes of sulfonamides
is unlikely. However, it is very important to evaluate the risk
of cross-sensitivity on a drug-by-drug basis, as some drugs in
the other categories are contraindicated in patients with a
sulfonamide allergy (e.g. celecoxib and hydrochlorothiazide),
while others carry different degrees of warnings and/or
precautions, often based the severity of the past reaction to
the sulfonamide (e.g. furosemide).
Continued on page 3
There are many articles and meta-trials discussing the
lack of differences between first generation (e.g.
representative example, haloperidol) antipsychotics
and second generation antipsychotics (e.g. atypicals representative examples, risperidone, quetiapine,
olanzapine) and between the second generations
themselves. In summary, for the purposes of end-oflife care utilization (i.e. agitation) and the role of
antipsychotics in the hospice population, there are no
significant differences in the effectiveness of
olanzapine over other, more cost effective, second
generation (or first generation) antipsychotics.
Preferred antipsychotics include haloperidol from
typical class and quetiapine or risperidone from
atypical class.
Individual patient’s characteristics should always be
considered, however, as hospice clinical pharmacists,
we have found that when significant differences exist
between the effectiveness of one second generation
over another, in the hospice population, that this is
generally indicative of an underlying mental health
disorder that has pre-existed for some time and then,
discontinuation or switching would not be
appropriate. It is also important to note that hospice
coverage of the controlling medication would also not
be appropriate due to the long history of the
condition. The extremely rare case would be in the
event of bipolar disorder, or schizophrenia (or other
significant mental disorder) that developed directly
due to deterioration of the brain, in a condition such
as dementia. The incidence of such a clinical event is
possible, but again, it is quite rare.
It is important to keep in mind, there are no
commercially available antipsychotic medications FDA
labeled as being indicated for the treatment of
dementia-related psychosis. Also, all antipsychotic
medications include an FDA Black Box Warning:
Elderly patients with dementia-related psychosis
Continued on page 3
Sulfa Allergy Cross-Sensitivity… Can a patient with sulfa allergy take morphine sulfate? Continued from page 2
It is always recommended to obtain as much detail as possible about the nature of the patient’s past reaction, including
specific symptoms experienced and their severity. This aids in determining whether a particular medication in one of
these categories should be avoided altogether or just monitored very carefully.
Regarding the question of a sulfa allergy and taking medications such as morphine sulfate.… Sulfates sulfur, and sulfites
are not sulfonamides, and are not chemically related to sulfonamides, and therefore do not cross-react, so a patient with
a sulfa allergy is not prevented from taking morphine sulfate due to a sulfa allergy.
Source:
Pharmacist’s Letter Detail document #260601: Sulfa Drugs and the Sulfa-Allergic Patient, June 2010, volume 26.
®
First and Second Generation Antipsychotics— a Focus on Zyprexa (Olanzapine) continued from page 2
with antipsychotics are at an increased risk of death compared to placebo. Most deaths appeared to be either cardiovascular
(eg, heart failure, sudden death) or infectious (eg, pneumonia) in nature.
Costs of selected strengths of medications mentioned in this article:

Olanzapine 5 mg (30 tablets): $396.04

Quetiapine 50 mg (100 tablets): $656.66

Risperidone 2 mg (60 tablets): $456.37

Haloperidol 2 mg (100 tablets): $50.56
Equivalent doses are approximately: Haldol® (haloperidol) 2 mg = Risperdal® (risperidone) 2 mg = Seroquel® (quetiapine)
75mg = Zyprexa® (olanzapine) 5mg.
Source:
Lexi-Comp Online. Lexi-Drugs Online, Hudson, Ohio: Lexi-Comp, Inc.; March 17, 2013
Lexi-Comp Online. Antipsychotic Agents, Hudson, Ohio: Lexi-Comp, Inc.; March 17, 2013
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ProCare HospiceCare
The information provided within this newsletter is proprietary
to ProCare Rx. Any reprint or reuse of this information must
be approved via written consent.
Copyright 2013, ProCare Rx
1267 Professional Pkwy., Gainesville, GA 30507
Editor: Dr. Cody Midlam, PharmD, CGP
Executive Editor: Dr. Meri Madison, PharmD, CGP